Inadequate Nutrition & The Development Of Bed Sores In Nursing Home Patients

Sad but true, many nursing home patients are suffering from malnutrition.  While we often associate malnutrition amongst the homeless or people living in a third-world country, some studies suggest that between 35% and 85% of nursing home patients are malnourished.

As attorney David Terry points out in his blog post, "How Does Poor Nutrition Affect the Development of Bed Sores in Nursing Homes?" the rampant malnutrition can be associated with an increased risk of developing bed sores.

Poor nutrition results in a deterioration of body functioning.  Over extended period of time, patients without adequate nutrition tend to have organs that begin to fail and critical body functions begin to deteriorate and lose effectiveness.

As the largest organ of the body, your skin is one of the first places where the consequences of inadequate nutrition may be visible.  Malnutrition can result in the deminished effectiveness of the skin's natural resiliance to pressure and other factions that contribute to the development of bed sores (similarly described as pressure sores, pressure ulcers, or decubitus ulcers).

In addition to malnutritions reduction in the effectiveness in the skins natural resilancy, malnourishment of nursing home patients may also lead to other medical problems that contribute to the development of bed sores:

Reduction in Energy Levels: Malnourished people have less energy and consequently are unable to move on their own– resulting in a more time spent in one position.

Reduction in the bodies natural cushioning: A long-term consequence of malnourishment is loss of fat, muscle and tissue– that provide necessary padding particularly in bed-bound patients, the less padding the more pressure that is put directly on the body– thereby resulting in increased rate of bed sores.

Inadequate Nutrition & Hinderance of The Bodies Natural Healing Properties

David makes a great point regarding the important role nutrition plays in not just bed sore prevention, but also healing bed sores.  One of the most overlooked aspects of bed sore treatment is assuring that facilities provide additional calories and protiien for patients with advanced bed sores.

A nutritional consultation should be brought in for patients with open wounds (stage 3 or 4 bed sores) so the specific nutritional needs can be tailored to the patient need. 

Caregiver tip:

As family and caregivers it is important to recognize the severity of the medical complications that accompany malnutrtion.  As with many medical conditions, it is far easier to prevent malnutrition than to teat the accompanying medical complications that tend to develop over time.

Caregivers should be on the lookout for the following: 

  • Look out for physical signs of malnutrition: diarrhea, disorientation, drastic weight loss, reduced urine output or cracking skin
  • Request a speech tharapist consult if your patient has difficulty swallowing 
  • For bed bound patients, make sure meals are within reach of the patient and there is staff present to assist
  • Ask about nutritional supplements for patients who are weak or have exhisting bed sores

Related Bed Sore FAQ's:

Can malnutrition cause bed sores?

Are the development of bed sores during a nursing home admission an indication of nursing home neglect?

Extra Calories Essential For Pressure Sore Patients To Heal Wounds

Nursing Home Injury Laws

In times of need, locating necessary information regarding the legal rights and resources for nursing home patients can be difficult and imposing.  In this respect, we are proud to introduce a new resource for patients, families and practitioners looking for a concise compilation of information regarding nursing home laws.  Nursing Home Injury Laws, provides every states':

  • Nursing Home Laws
  • Medical Malpractice Laws
  • State Resources
  • Applicable State Code

Additionally, we will be posting regular updates regarding important developments relevant to nursing home care within each state.  Here is a link to Nursing Home Injury Laws.

Autopsies May Help Families Determine If Their Loved One Was A Victim Of Nursing Home Neglect Or Abuse

Deciding whether to have an autopsy performed on a loved one is indeed a very personal decision for a family to make following a death.  An autopsy can help a family get answers to not only the cause of death, and in the case of potential nursing home negligence, what-- if any, errors may have been made by a medical facility that may have caused the death.

After reading this news article about how a disabled nursing home patient may have 'choked to death' on his lunch I was reminded by how valuable autopsies can be where a death may occur in a nursing home or hospital setting that is insulated from the public.

What is an autopsy?

An autopsy is a detailed medical examination of the person's body and organs following death to establish the specific cause.  Autopsies are performed by a physician, a pathologist, who is trained to evaluate results from physical examinations and laboratory results from tissue and blood samples to determine the cause of death.

Once the examination and laboratory results have been evaluated, an autopsy report is rendered. The report notes the physical findings and states a cause(s) of death.  Because the report is rendered from an impartial author, it can be particularly useful in a litigation setting.  Similarly, just a the report may be useful in case against a nursing home or hospital, results may also absolve the facility of responsibility if the results do not substantiate poor care. 

In order to secure the most accurate results, most pathologists suggest performing an autopsy 24 to 48-hours after the death of a person.  Depending on where the death occurred  and the circumstances surrounding it, the autopsy may be performed by the state medical examiner or by a physician at a private hospital.

Is an autopsy called for in cases where nursing home neglect may have occurred?

In my opinion, particularly in cases involving the elderly, autopsies can be extremely helpful in rebutting arguments made by facilities who may argue that a death was the result of 'old age' or due to a 'variety complicated medical factors'.

Autopsies can be particularly helpful in the following wrongful death matters:

If you wish to have an autopsy performed on a loved one, you should contact your coroner or local hospital to get information about facilities that can perform one at your request.

Related Nursing Homes Abuse Blog Entries

Autopsy Confirms Man Was Murdered In Chicago Nursing Home

Medical Examiner Rules Tennessee Nursing Home Death A Homicide

Grandson Alleges Poor Nursing Care Results In Bed Sores "You Could Stick Your Fist" In

Nursing Home Staff Must Pay Special Attention To Avoid Complications When Caring For Patients Dependent On Feeding Tubes


Many nursing home residents require feeding tubes because of illness or weakness.  In order to maintain a resident’s strength and health, a feeding tube can be used to either supplement eating by the mouth or completely replace a resident’s meals. 

Good nutritional habits are especially important for residents who are already suffering from illness, trauma, or weakness.  Eating a well-balanced diet gives residents strength and may help them fight infection. 

 When a nursing home resident’s dietary needs cannot be met by eating a well-balanced diet, the resident might be placed on alternative means of nutritional support such as a feeding tube. 

One of the most common reasons for a feeding tube is cancer, especially of the head, neck, stomach, and esophagus.  Other conditions such as Crohn’s disease, ALS, stroke, surgical bowl removal might also require a feeding tube. 

A feeding tube might be needed if a resident has:

  • Severe nutritional problems
  • Severe dehydration
  • Aspiration pneumonia on several occasions
  • Great fear of suffocation from choking or aspiration

A feeding tube can be either a short-term or long-term solution for a resident’s nutritional needs.  If the nursing home staff is concerned about a resident’s nutritional health and well-being, a doctor and nutritionist will determine where the feeding tube will be placed (through the nose or directly into the stomach) and the feeding formula.  Usually, a feeding tube is not employed unless all attempts at feeding by mouth have been tested. 

A doctor will decide the best plan for feeding based on the resident’s gastrointestinal function, physical capability, and degree of cooperation.  The feeding formula can range from blended food products to commercial formulas.  There are several types of feeding tubes: G-Tube, PEG (percutaneous esophago-gastronomy, placed directly into stomach), J-Tube (Jejunostomy Tube, placed directly into small bowel and stomach), NG-Tube (Nasogastric Tube, placed through nose). 

The G-Tube is surgically placed into the abdominal wall, below the rib cage and goes directly into the stomach.  It is a convenient delivery route for long-term feeding and can be easily replaced.  The J-Tube is surgically placed into the upper section of the small intestine (jejunum).  This tube bypasses the stomach and feeds directly into the intestinal tract.  The NG-Tube is placed in a nostril, down the pharynx, through the esophagus, and into the stomach.  It is usually used for short-term feeding.  The placement of the tube must be checked before each feeding. 

There are also several methods for formula delivery: bolus/syringe method, gravity drip method, and pump feeding.  The bolus/syringe method uses a syringe attached to the feeding tube.  The formula is poured into the syringe and flows into the tube.  The gravity drip method uses a gravity feeding bag.  The flow rate (determined by a doctor) can be controlled, and the bags must be changed every 24 hours to prevent bacteria growth.  The pump feeding method is controlled by a battery or electrical operated device set to control the rate of infusion. 

Complications with feeding tubes can occur, so nursing home staff must closely monitor residents’ feeding tubes.  The feeding tube can become loose, and aspiration can still occur with a feeding tube in place.  Therefore, it is important that the head remain above the level of the tube.  In addition, care must be taken to prevent the growth of bacteria in feeding tube formula.  Some bags have an ice pouch on the outside to keep the formula fresh, and bags must usually be changed every 24 hours. 

Nursing home staff must also take extra precautions to prevent infection of the feeding tube and cause the resident further health problems.  For feeding tubes that are surgically placed, greater care is required during the first week the tube is in place to prevent infection and prevent the tube from pulling away from the abdominal wall.  For tubes placed directly into the stomach, care must be taken to keep the skin surrounding the tube clean and dry, and in some instances, covered with gauze.  Furthermore, gastric leakage can occur with the stomach feeding tubes.  This is problematic because the gastric juices are acidic and can cause skin irritation.

Most commercial feeding formulas are not very thick and do not leave a reside so that they do not clog the tube.  The nursing home staff must still take precautions to prevent clogging including flushing the tube with water before and after feeding. 

Many nursing home residents are at risk for illness and injury, so it is important to keep their strength up.  Therefore, feeding tubes are an important method to help maintain residents’ health and well-being.  It is important to know that additional complications can occur with feeding tubes.  If your family member is a victim of feeding tube complications, I would honor the opportunity to discuss your situation.  As always, our legal services are completely free if there is no recovery for you.  Speak to our experienced nursing home lawyers today.  (888)424-5757.

Extra Calories Essential For Pressure Sore Patients To Heal Wounds

A nutritious, balanced, and appetizing diet is important for all nursing home residents.  But it becomes essential for those suffering from pressure sores.  This is because a person with pressure sores needs to consume more calories per day that their healthy counterparts. 

Facilities need to calculate each patient’s total energy expenditure (TEE) in order to meet their nutritional needs.  TEE is composed of three components:

  • basal metabolism, that is the number of calories needed to maintain a body at rest, which depends on age, sex, and body size;
  • voluntary activity such as exercise; and
  • energy expended to consume and metabolize food.

In times of injuries and stress, a body’s metabolic rate may increase, which in turn requires additional calories to compensate.  The extra calories provide the energy for the body to react to the stress of injuries and heal wounds.  So, while a normal person may need only 25-30 kcals per kilogram per day, a person with moderate illness or injury needs 30-35 kcals/kg, and a person with critical injury or illness needs 35-40 kcals/kg.  

Proper treatment for pressure sores must involve an assessment by a qualified dietitian who can figure out how many calories the patient should be consuming in order to heal and the best way to help the patient get the necessary calories from a balanced and appetizing diet.

Many facilities overlook, this crucial component to healing pressure sores.  Using the above nutritional guidelines, patients with advanced pressure sores would require the following daily caloric intake:

  • 100 lbs.: 1,587 - 1814 daily caloric intake
  • 150 lbs.: 2,381 - 2,721 daily caloric intake
  • 200 lbs.: 3,175 - 3,628 daily caloric intake

In most cases, facilities must provide additional snack and nutritional supplements in order for patients to achieve this level of calorie intake.  If facilities fail to provide adequate levels of nutrition, the pressure sores are like to to advance and additional complications may develop.

Source: Nancy Collins, PhD, Rd, LD/N, FAPWCA, Why Calories Count: Proper Nutrition Fuels the Wound Healing Process.

 

 

Medical Examiner Rules Tennessee Nursing Home Death A Homicide

Labels frequently get tossed around when describing nursing home lawsuits.  Admittedly, some of these descriptors such as 'abuse' or 'neglect' get overused by people who may have a 'vested interest' in the matter-- family members, friends and attorneys.  When an independent investigator applies 'neglect' to his findings, more people should take notice.

"Nursing home neglect" resulting in dehydration is what a Tennessee Medical Examiner ruled as the cause of death following the autopsy performed on 46-year-old Linda Carter.  Carter died on March 27th at the at the University of Tennessee Medical Center following a nine day admission to Hillcrest North Nursing Home.  Carter was admitted to Hillcrest for rehabilitation from injuries sustained in a car accident.

When Knox County Medical Examiner,  Darinka Mileusnic-Polchan, examined Carter's body he noted the following visible signs of dehydration:

  • Poor skin turgor
  • Sunken eyes
  • Concentrated urine
  • Empty stomach and proximal small intestine

These autopsy results will not doubt provide added ammunition to the wrongful death lawsuit filed by Carter's children.  The lawsuit against Hillcrest seeks $7 million in compensatory damages and $28 million in punitive damages.  

Currently, the Tennessee Bureau of Investigation (TBI) is conducting its own investigation into the death.  TBI spokeswoman, Kristin Helm indicated that criminal charges may be filed against Hillcrest as well.  "We are looking into it as a suspicious death," Helm said.  " We met with the (Attorney General) and he asked us to look into it more, to review it and come back and meet with him again."

Read more about the medical examiner's finding here.

View The Final Autopsy Report 

Related Nursing Homes Abuse Blog Posts

Damages

Appellate Court Orders Retrial In Nursing Home Negligence Case With $29.8M In Punitive Damages

Family Seeks Punitive Damages Against Nursing Home For Death Involving Malnourishment Of 84-Year-Old

Tennessee Legislature Attempts To Limit The Rights Of Injured Nursing Home Residents

Grim Details Emerge Regarding Malnutrition In Kentucky Nursing Home

As we recently discussed, Winchester Centre for Health and Rehabilitation may lose its Medicare and Medicaid funding if it fails to correct the dangerous conditions inspectors have recently found at the facility.  The federal Centers for Medicare and Medicaid Services have given the facility a February deadline to correct the problems or federal aide will be pulled and daily fines will be imposed.

The Lexington Herald-Leader, ran an article detailing the deficiencies documented in recent inspections of the facility obtained via the Open Records Act.  Among the more disturbing situations detailed in the report:

  • A resident lost 87 pounds during a 19 day admission to the facility
  • Staff repeatedly failing to notify physicians for deterioration of residents physical condition
  • Administering the wrong dosage of an anti-seizure medication for 40 days to a resident.  The resident was prescribed 450 milligrams of extended release capsules by mouth, but the nursing home staff gave the resident 400 milligrams by feeding tube, which altered its effectiveness.  Consequently, the patient suffered a seizure.
  • Staff failed to follow doctors orders for patients with serious medical conditions
  • Problems with cleanliness, equipment disrepair, and temperature of food served to residents

What is particularly disturbing about these findings, is that the nursing home staff acknowledges the poor conditions- yet was ineffective in doing their job to stop them from occurring in the first place.  When questioned by a state inspector about the precipitous weight loss of a resident, the medical director of the facility stated, "It was not a good experience during his three-week stay, and I think he suffered for it."

Malnutrition In Nursing Homes

Poor nutrition and dehydration are common in nursing home residents and are associated with many adverse clinical outcomes. OBRA (Omnibus Budget Reconciliation Act) guidelines require nursing homes to provide adequate nutrition to their resident.

Despite facilities obligation to provide proper nutrition to its residents, two out of five nursing home residents suffer from malnutrition, and dehydration. Malnutrition in nursing home residents can occur for a variety of reasons, including the resident's inability to process food and ill-fitting dentures. Dehydration can occur for a variety of reasons as well, including diarrhea and the effects of medication. Unfortunately, malnutrition and dehydration can also occur due to a nursing home's negligence in a variety of situations, including:

  • Failure of the nursing home to employ adequate staff, which results in the staff's inability to properly feed the residents
  • Failure of the staff members to pay adequate attention to those residents needing assistance with eating
  • Failure of the nursing home to properly educate the staff on nutrition and feeding methods
  • Failure of the nursing home to provide proper supervision over those who provide nutritional services
  • Reliance on liquid supplements as opposed to making sure each resident eats enough food to get necessary vitamins, minerals, protein, and calories

If you notice that your loved one has signs of malnutrition or dehydration or if you think that they are not getting enough food or fluids at the nursing home, you should immediately notify the nursing staff and the physician to prevent potentially serious, life-threatening consequences.

Nursing Home Fined In Dehydration Death

California nursing home regulators have fined El Dorado Care Center $21,000 for violations that led to the death of 86-year-old resident Donald Forseth.  In 2006, Mr. Forseth died within four months of his admission to this nursing home from complications related to dehydration

A complaint was filed against El Dorado Care Center by Foundation Aiding the Elderly, a patient advocacy group shortly after Mr. Forseth's death.  Almost two years after the report of nursing home neglect was made, the state Department of Health Services found that the facility failed to monitor the man's fluid intake, which led to severe dehydration, kidney failure and death. It also faulted the center for staffing deficiencies and other problems.

According to Carole Herman, president of Foundation Aiding the Elderly, "It took them almost two years to adjudicate this case," Herman said. "That is ridiculous and unacceptable.  The state is not doing its mandated monitoring of nursing homes in a timely manner, which causes many more abuses to occur."

During the course of the state investigation Herman said that Forseth's widow, Patricia, received a settlement from the civil case against El Dorado Care Center in the.  Read more about this incident involving dehydration here.

Dehydration is a common problem amongst elderly in nursing homes.  Elderly are susceptible to dehydration for several reasons including:

  • Failure to detect thirst
  • Inability to control body temperature
  • Embarrassment over using the toilet
  • Medications that act as diuretics

It is the responsibility of the nursing home to ensure that residents remain properly hydrated.  Most situations involving dehydration are preventable with simple monitoring of fluid intake.  If the facility fails to monitor fluid intake and dehydration ensues, they are responsible for nursing home neglect.

 

Food Safety

An 85-year-old woman died following a norovirus outbreak in a nursing home.  The woman's death comes shortly after the deaths of 10 other nursing home residents related to gastroenteritis outbreaks. 

The norovirus outbreak in an Australian nursing homes demonstrates the susceptibility of the elderly to food born illness. There is no cure for people afflicted with norovirus.  Rather, the symptoms need to be managed by increasing fluids, increasing electrolytes, monitoring for dehydration and careful observation to prevent overall weakness.

Norovirus outbreaks are common in amongst people in closed or crowded quarters such as nursing homes or hospitals as the virus is very contagious.  Diarrhea, abdominal pain, and vomiting are the most common symptoms associated with norovirus.  Most symptoms develop 24 to 48 hours after exposure to the contaminated food. 

Norovirus and other food related illnesses are preventable.  Simple steps can eliminate the risk  to nursing home residents contracting a food related illness or food poisoning:
  • Use correct handling of food
  • Strict hand washing after bathroom use
  • Give kitchen workers paid sick leave
  • Liberal use of  disinfectants
  • Discard food that has been left unrefrigerated for long periods of time
  • Discard food that is past its expiration date
  • Keep residents infected with disease separate from the general population
Learn more about Norovirus here.

Below are other types of food related illnesses that have occurred in nursing homes throughout the country:

Meals: Nutrition vs. Neglect

Today my office was contacted a Chicago-area woman whose mother lost 30 pounds within three months of her admission to a nursing home.  She explained how her 87 year old mother suffered from dementia and needed assistance with most daily living activities including help with meals.  The woman went on to explain that the entire reason she brought her mother to the facility was because she was assured that the facility was capable of meeting her daily nutritional needs.

The case above illustrates a common problem at many nursing homes and long-term care facilities--the neglect of residents.  Neglect related to the nutritional needs of nursing home residents is perhaps one of the more dramatic areas of neglect.

A drastic weight loss or gain can be indicative of poor care.  This article from the FDA discuses the nutritional problems encountered by many elderly.  Paul Kerschner, vice president of the National Council on Aging discusses how "seniors tend to be at a disproportionate risk of poor nutrition that can adversely affect their health."  Kerschner estimates that 15 to 50% of the elderly population are affected by poor nutrition.

Poor nutrition typically plays a role in most injury related nursing home maladies such as: bedsores, falls, decline in cognitive function, and an overall decline in quality of life.